Ruminations by a non-academic general surgeon from the heart of the rust belt.

Tuesday, January 27, 2009

The New Standard

I have strong feelings on the laparoscopic appendectomy. So strong that if I were an associate professor of surgery at the University of Bigshot I would be trying to crank out a paper every few months in support of it's beauty and efficacy. In any event (I know, I know, I ought to write up my experiences anyway) I have a series of over 150 patients with acute appendicitis who have been treated by moi with laparoscopic exploration, appendectomy, and sometimes peritoneal lavage (depending on severity of contamination). This series includes all comers; simple early appendicitis, advanced appendicitis, and even cases of purulent peritonitis. The end reslt: 0% infection rate. No superficial wound infections, no intra-abdominal abscesses, nada, zilch, nothing. (You see, in a paper for Annals of Surgery you can't write something like 'nada, zilch, nothing' without prevailing editorial compunction like you can in a blog {I know, lousy excuse}) I think that's pretty good. Zero percent. Maybe I'm getting ahead of myself, maybe my next ten appies will have infectious complications, thereby evening everything out knock on wood, but I think maybe I'm on to something. And then I had this case from a few weeks ago that affirmed my faith in the Justice and Truth of Glorious Laparoscopic Appendectomy.

The patient was a 14 year old girl who had been ill for 5 days. In the ER they diagnosed "gastroenteritis" based on a normal WBC count and diffuse pain and admitted her to the floor. The alert pediatrician noticed that the girl's differential showed over 70 bands (I've never seen such a left shift). So she ordered a CT scan that ultimately demonstrated advanced appendicitis and ascites with multiple fluid collections. When I saw the patient she looked like hell. She was 14 years old and she looked on the verge of something awful. Her kidney's were starting to fail and she was having a hard time keeping her blood pressure up. We started antibiotics and rushed her to the OR. We being me. The appendix was obviously perforated and gangrenous and it came out in a matter of minutes. But the damage had already been done. As I rotated the laparoscope around the abdominal cavity I saw pools of pus everywhere. Inflammatory adhesions from the bowels to the abdominal wall spanned the insufflated gap like Spider webs in an old barn. (The pop cultural influence and irresitibility of Spider Man contributed to the unfortunate reflex capitalization in the preceding sentence). So I asked the circulating nurse to get several of the 3 liter saline bags used in urological cases. I was methodical. I started in the right upper quadrant. I aspirated all the gross pus and then proceeded to irrigate/aspirate, irrigate/aspirate, irrigate/aspirate in a soporofic manner (it was after 2 am) until I was satisfied. Then I moved to the right lower quadrant. Then left lower quad. Then up along the left paracolic gutter and splenic flexure. I irrigated like I was watering a lawn in the Arizona summer. My assistant had brought his Ipod and we listened to everything Meatloaf has ever recorded (not my choice but I usually defer music selections to staff for after hours cases). The case took a little over an hour. I left a Jackson-Pratt drain and sent her to the ICU. The pediatrician called me the next day and asked about possible transfer to a tertiary referral center. Not yet, I said. I had this one. Every day her bands decreased. Her CRP (c-reactive proten, an indicator of overall body inflammation) gradually came down. One day on rounds I walked in and she was putting on make-up and her boyfriend was holding her hand. We need to start thinking about getting you out of here, I said. Her mom concurred. The boyfriend blushed and looked at his cuticles and slowly, but not unnoticeably, withdrew his hand from my patient's.

She went home. She went back to school. It was what we like to call in the professional parlance, a "good outcome". But hell, that's what I expected. That's the way lap appies are supposed to go. After all, I've done over 150 of them already (yeah yeah, I know I said the already.) I reviewed the literature (yeah, we do that in the hinterlands of non-academic medicine) and the data on laparoscopic appendectomy is a litle surprising. You can go to Pubmed and review it yourself but here's the bottom line: laparoscopy is at least as good as open appendectomy although the incidence of intra-abdominal abscess is clearly higher. The italics are utilized for authorial disbelievability. It simply can't be true. Seriously. An open appendectomy implies a limited incision in the right lower quadrant. The visualization is limited. You have no idea what is going on in by the spleen. Sometimes you can shove the sucker down into the pelvis but it's all blind maybe you break into a pus pocket maybe you dont. Maybe you miss a peri-colonic abscess. Laparoscopically I control that point of view. I see that appendix. I see that splenic flexure. I see the gallbladder. I see directly down into the pelvis. So, assuming I intervene appropriately (i.e. aspirating, irrigating, etc) why would there be a higher abscess rate compared to open appendectomy? It simply doesn't make sense. I can irrigate and aspirate and totally control the post operative appearance of the intra-abdominal cavity. Isn't that better, theoretically, than what the open approach affords? Assuming you do it right?

Listen, I'm just a small town (rust town?) general surgeon. I have no academic credentials that ought to sway a patient to choose one form of treatment versus another. But I do have my personal experience. So if you have appendicitis; get thee to a laparoscopist, why wouldst thou be a breeder of infectiousness?

18 comments:

I agree with you except there is a subset of patients in whom cost is the differentiating issue- i.e. the 12 year old, rail thin, pain <24 hours, early appendicitis on CT scan. How is the laparoscopic approach better for this patient? I believe everything else to be equivalent clinically in this setting, therefore, it is a responsible choice to open.

I am a Big believer in the laparoscopic approach. I think you can see more, do more, and clean more laparoscopically. But this is where I think people fail. I don't know if all folks do a good job using table maneuvers to help get you everywhere you need to be in order to get things clean. I think people miss looking over the dome of the liver. Finally, I think that the studies done to date are small and underpowered or old and out of date. Therefore I do not think they represent the reality of current laparscopic appendectomies.

Even though I consider myself the luckiest surgeon I know... I still am not as lucky as you (nor as good apparently). I have had to convert 7 out of my last 54 appendectomies. And don't think I didn't try hard not to. In fact, I went so far as to place a handport for one patient just to see how that would go (It went, but at a tremendous time cost). All that being said, no postop wound complications or retained abscesses in either group. But my partners have had two postop intraabdominal abscess with one leading to liver abscesses (very unusual).

I would be interested in knowing your take on antibiotics (what you use and when you stop). I would like to know your technique (port placement, etc.)

Final point. Possibly its the efficiency at which you operate that has an impact. Uncomplicated appendectomies can take me 15 minutes, but my residents need 30. And oh my gosh.. if its perforated and socked in. Whoa, I need to bolus a PPI before starting that with a 3rd year.

Oh. I almost forgot. You do have the academic credentials to say anything you want. The American Board of Surgery and your experience gives you that right.

Ohmigosh. You have so, so so jinxed yourself. No infections? You might as well just go ahead and hock a loogie in your next half dozen appys, cause they're going to get infected. Trust me. You've committed the sin of hubris, and you will be punished. Trust me -- I've been there, and I know from karma

Sucher-I agree, technique is everything. You have to look around and use your suction irrigator to your advantage. I place a midline 5mm suprapubic, a LLQ 5mm, and a periumbilical Hasson. Rarely I need another RUQ 5mm for tough retrocecal apps. I keep IV antibiotics on for at least 24 hrs. Kids are kept on Zosyn until right before discharge. Perforated/gangrenous apps go home with augmentin.

Shadow- I realize the inherent risks of this post. But i did knock on wood and sacrifice a hamster to the Karma gods. Seriously though, the literature is dominated by articles (Cochrane review included)that claim lap appy increases your risk of post op abscess and that just doesn't make any sense. Why would better visualization, better access to the intra-abdominal cavity increase your risk of abscess? I think as we go further into the lap era (with more experience and technical refinement) we'll start to see more papers that propound the opposite....

I completely agree with you about the virtues of the lap appy. I've done 110 appys. I have 1 abscess and 2 wound infections - all in patients who I opened. Admittedly there is a selection bias here, but I've done plenty of bad, bad perfed appys with peritonitis completely lap with great results as you have done.

I think the published data is from folks who really did not know how to use the tools to best effect.

Regarding antibiotics - you're using too much. Early disease needs one dose only pre-op, none post-op. Gangrenous or perfed, follow Harlan Stone's criteria - safe to stop antibiotics when afebrile for 24 hrs with normal WBC and normal diff. Almost never do you need more than 5 days treatment. Zosyn is for complicated infections. Try cefoxitin, unasyn, or ertapenem.

Dr. Lazaron, my group administers antibiotics in exactly the same manner that you have cited. This is always a point of disturbance. It is very difficult to get people to stop antibiotics "early". That being said, we do have one case of a serious postoperative liver abscess after appendectomy for complicated appendicitis (total number of cases = 230). The patient did not have a retained intra-abdominal infection, but instead manifested 2 weeks post op with failure to thrive. CT revealed multiple small liver abscesses that responded to intravenous antibiotics.

Despite the fact that we all love laparoscopic appendectomy (and it is not going away, just like laparoscopic cholecystectomy), the literature continues to be damning. Just in this last issue of JACS, another article has been published that shows more evidence that it is a higher cost, and has more complications Laparoscopic Appendectomy—Is it Worth the Cost? Trend Analysis in the US from 2000 to 2005 . The worst part is that this article comes from my old medical school at The University of MO-Columbia.

This is one of those papers that really burns my chaps. I just have no faith in any study that draws information from discharge databases, aggregating them, and then performing retrospective analysis. Have you ever looked at discharge data? It is a joke. You can't tell if a patient had an appendectomy or a right hemicolectomy half the time. Its horrible, but this is the type of article that drives policy at a national level. Why? Because the numbers are tremendous... They "looked" at over 132,000 appendectomies performed over a 5 year period of time. That has to be right... right? Ugg.

I saw the study you refer to regarding lap vs. open appy and costs. I was not impressed. The study actually advocated lap appy only for perforated disease - presumably since the extra cost of the equipment gets lost in the cost of the hospitalization, and since there are fewer wound infections. The average length of stay for early appendicitis was not appreciably different, lap vs. open, and was longer than I see in my hands. I more often than not send folks home after lap appy for early disease within 24 hours. I think that is hard to do for open appy, unless you make a fetish out of getting it done through a 2 cm incision - which poses it's own risks. For me, the proof is in the patient satisfaction, and the decreased wound complications. Of course I also find the lap appy a much more elegant and satisfying operation, and a better tool to evaluate the abdomen in the cases where the appy is normal.

Of course these "studies" are nothing of the sort as you note. They are retrospective chart reviews with very limited data-mining value. I fear we would be better off not publishing them and not providing ammunition for the idiots.

Anonymous resident poster from Minnesota: feel free to get in touch with me at my email address - victorlaz@yahoo.com.

[Once upon a time, at a hoity-toity Ivory Tower, I wrote a paper equivalent in tone and style to this post of yours -- Very Important But Still Fun. My usually kind diss director wrote the following in blood-red ink just below the highest possible of grades:

"You have not yet earned the right, you have not put in the time, to merit using such a pert and casual style within the academy..."

Bianca- The word "hand" is implied, and I sort of liked the nebulousness of the way the senetence ended.

NtoD- Bands refer to immature white blood cells. In sepsis, the marrow mounts a massive production effort to create new white blood cells. This may not manifest early on as a true leukocytosis. Look at the differential on the CBC. It will show a "left shift" (increase in neutrophils/bands).

I believe there are two important questions with the lap appy: port selection and irrigation. I noticed that you use open peri-umbilical Hasson, and 5mm LLQ and suprapubic. (personally I use Hasson periumbilical, 5mm suprapubic and 12 mm LLQ.) So I assume that you switch camera to 5mm port and use stapler via Hasson--true? I've been thinking of adopting that myself for better cosmesis and to lose the 12mm closure. I have used the lasso sutures but, while they are cheap and only require a 5 port, just don't seem as secure. I have been thinking of this a bit and am also considering making a Hasson in the actual umbilicus for cosmesis. The argument against is that it would be a mess if it were to become infected, but would render the operation virtually scarless otherwise.

The other question is irrigation. The rationale that makes sense to explain the higher intraabdominal abscess rate with laparoscopy is that you spread germs with the irrigation. So I suck before irrigating and don't irrigate uninvolved areas, but, I must admit, it makes more commonsense to just drench everything. Thoughts?

As an ER doc who had a lap appy about a month ago, I was quite grateful for the procedure. What started as a hell of lousy night shift ended up with me in the OR (after more than a good bit of denial that it "was just the hospital food.") Appy out that evening, home the next morning, on a plane "back west" for Christmas the following day, and back in the ED to work 5 days later.

If I wasn't grateful, you can bet my colleagues were. Of course, I wasn't the one mucking around in there making sure I hadn't perfed while tubing and tapping the kid in status epilepticus the night before...

VLaz- Nice work! I've sent some home same day, like if I did it at 5 or 6am... always a good feeling.

Anon- I just think the angles generally line up better when you push the GIA through your peri-umbilical port (Hasson). If we were at a starbucks, I'd sketch it on the back of a brown napkin. And I make my umb incision transversely on the downslope of the umbilical depression. Cosmesis is terrific. I wouldn;t mess around with cutting the actual umbilicus; the closure gets messy...

I apologize if I missed this -- if the patient presents in a straightforward manner, is it possible to do the laparoscopy without using general anesthesia?

Also, just wondering (la di da di da...), but when do you consider a C-RP worrisome (by value)? As a surgeon, if one just sort of sits at the same elevated value in a patient with known infection -- over a period of months -- does it really have any predictive worth at all? (whistling Dixie...)

Yes, I *could* go take a hike!

Since I was such a goofhead in my first comment, let me just say that the shift toward minimally invasive surgeries seems like a win-win-win situation -- for patient, doctor, and the general economy, as well, with such a reduced down time and fewer costly complications. Now if every surgeon were just equally talented in the procedures...

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